HCPCS Modifiers X-EPSU

​​​​​The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.

Modifier 59 is the most widely used HCPCS modifier. Modifier 59 can be broadly applied. Some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)." This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.

The primary issue associated with modifier 59 is that it is defined for use in a wide variety of circumstances, such as to identify:

• Different encounters;
• Different anatomic sites; and
• Distinct services.

​ Modifier 59 is

• Infrequently (and usually correctly) used to identify a separate encounter;
• Less commonly (and less correctly) used to define a separate anatomic site; and
• More commonly (and frequently incorrectly) used to define a distinct service.

Modifier 59 often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is ​needed to reduce the errors associated with this overpayment. Therefore they have created 4 new modifiers as a subset of modifier 59.

​XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

​CMS will continue to recognize modifier 59, but notes that Current Procedural Terminology (CPT) instructions state that modifier 59 should not be used when a more descriptive modifier is available. While CMS will continue to recognize modifier 59 in many instances, it may selectively require a more specific   X{EPSU} modifier for billing certain codes at high risk for incorrect billing. The X{EPSU} modifiers are more selective versions of modifier 59 so it would be incorrect to include both modifiers on the same line. The AAP has been working with other payers to determine how they will handle the use of the new X{EPSU} modifiers and we are tracking that.

Vignette:

A patient presents to your office after a fall. Patient sustains injuries to the palm of her hand and knee. The palm of her hand has an embedded foreign body and the knee has a 2.3cm laceration requiring sutures.  The physician performs and incision and removal of the foreign body and places two sutures to close the wound. The physician also performs the laceration repair on the knee. Because the incision and removal code contains suture placement, it is important that the payer knows the suture placement was done on a separate anatomical site and not part of the work of the other procedure.

10120 (incision and removal of foreign body, simple)

12001 XS (laceration repair, 2.5cm or less including extremities)

For more details refer to:

• Coding Newsletter article 
• AAP News: Abuse of modifier 59 spurs addition of 4 new HCPCS modifiers